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Clinical Guide to Transfusion Clinical Guide to Transfusion Online edition published at www.transfusionmedicine.ca by Canadian Blood Services with Gwen Clarke and Sophie Chargé as editors. Fourth edition published online in 2007 by Canadian Blood Services with Gwen Clarke and Morris Blajchman as editors. Previous editions published by the Canadian Red Cross Society with Anita Ali as editor. © Canadian Blood Services, 2013. All Rights Reserved. Extracts of the information may be reviewed, reproduced or translated for educational purposes, research or private study but not for sale or for use in conjunction with commercial purposes. Any use of the information should be accompanied by an acknowledgement of Canadian Blood Services as the source. Any other use of this publication is strictly prohibited without prior permission from Canadian Blood Services. Care has been taken to trace ownership of copyright material contained in this text; however the publisher will welcome any information that enables them to rectify any reference or credit for subsequent editions. The content of this publication is that of the authors of the materials, papers, publications and proceedings. The material in this publication is provided for informational purposes only. The editors and publishers do not assume any and disclaim all liability for loss, injury or damage arising form any use made of any information, instructions, ideas, and recommendations therein. *********************************************************************************************************************** Clinical Guide to Transfusion Online Edition Gwen Clarke and Sophie Chargé It is with great pleasure that we present the transfusion medicine community this online edition of the Canadian Blood Services’ (CBS) Clinical Guide to Transfusion. The Guide continues to be the result of efforts by CBS to address the educational needs of health care workers relating to the provision of blood products and transfusion medicine services in Canada. The authors of the Chapters are experts in their fields of endeavour. They have provided excellent and very practical summary of our current knowledge of blood components and transfusion medicine practices. The information in this online edition is being updated on a regular basis to reflect the evolution of transfusion medicine practices. We hope that you find this Guide to be clear and useful. Above all, we trust that it will continue to help increase safety of those Canadians who require blood products and add confidence for those who provide the services. Enjoy! Clinical Guide to Transfusion (On-line edition at www.transfusionmedicine.ca) Cover Page (Updated March 2013) Clinical Guide to Transfusion 2. Blood Components Kathy Chambers, Pat Letendre and Lucinda Whitman; Revisions by Gwen Clarke 2013 Introduction Whole blood donations are separated into specific cellular (red blood cells (RBC) and platelets) and plasma components. This enhances the utilization of individual donations and decreases the need for whole blood. Transfusing the appropriate combination of components effectively provides for the clinical needs of patients and best utilizes the donated blood. At Canadian Blood Services (CBS), whole blood is collected from donors into a multiple bag system in which all bags are connected, allowing blood and components to be moved between bags aseptically. The collection packs include two different configurations. One, the buffy coat collection system (also referred to as B1), is used in the production of RBC, plasma and platelets components; the other, a whole blood filtration system (also referred to as B2), is used in the production of RBC and plasma components. Some of this plasma from the whole blood filtration system may be further processed into cryoprecipitate and cryosupernatant plasma. Both whole blood collection sets contain a citrate-phosphate-dextrose (CPD) anticoagulant. Apheresis technology may also be used for collection of some blood components, including plasma and platelets. This collection procedure utilizes an automated in-line process in which whole blood from the donor enters a collection chamber where flow patterns separate the plasma from cellular blood constituents such as leukocytes from platelets. Plasma, or platelets suspended in plasma, are collected into a bag while the remaining constituents of the blood are returned to the donor. All cellular blood products produced by CBS are white cell reduced, referred to as leukocyte reduction (LR), by leukocyte reduction filtration or (in the case of apheresis platelets) during the apheresis procedure. Plasma components are not uniformly leukoreduced by filtration; however processing steps maintain a residual leukocyte level that averages <5x106 per unit. (Some CPD units may contain ≥5x106 leukocytes per unit thus the label for these plasma components does not indicate leukoreduction). Plasma products produced by the buffy coat method are not leukoreduced by filtration however this production method does reduce leukocyte numbers through centrifugation and separation of the buffy coat layer. Plasma produced by whole blood filtration is leukoreduced as the whole blood is filtered. There is no known therapeutic benefit to leukoreduction of frozen plasma, a non cellular component. This chapter describes the commonly prepared components (Red Blood Cells LR SAGM added, Pooled Platelets LR CPD, CPD Frozen Plasma (FP), Apheresis Fresh Frozen Plasma (FFPA), Cryosupernatant Plasma (CP), Cryoprecipitate), their indications, contraindications, storage and transportation requirements; and briefly describes dose, administration and available alternatives. Further information may be found in Chapter 9 and Chapters 11 to 18 of this Guide and in the CBS Circular of Information. Clinical Guide to Transfusion (On-line edition at www.transfusionmedicine.ca) Chapter 2 (Updated March 2013): Page 1 of 16 Clinical Guide to Transfusion 2. Blood Components Transfusion must be prescribed and administered under medical direction, and documentation of the identity of the units transfused must be retained indefinitely on the recipient’s medical record. Documented informed consent should be obtained apart from in an emergency situation. No medications or drugs, including those intended for intravenous use, may be added to the unit. Infusion of components should begin within 30 minutes of removal from an approved temperature-controlled blood product storage device. Red Blood Cells LR SAGM added Description Whole blood is centrifuged to separate the RBC from the plasma and platelets. In the buffy coat production packs, filtration for LR occurs after initial centrifugation while for whole blood filtration packs, filtration occurs prior to centrifugation. The average volume of an RBC LR SAGM added unit is 304(+/-61) mL and it typically contains 57(+/-16) g of hemoglobin with a hematocrit of approximately 0.65 and has an average residual leukocyte count of 0.32x106. RBC LR SAGM added is the only RBC product prepared by CBS. RBC LR SAGM added units are prepared from whole blood collected in CPD anticoagulant. The units are plasma reduced by centrifugation and platelet reduced by either centrifugation or filtration as well as filtered to reduce leukocytes. After removal of most of the plasma and/or the buffy coat, the additive solution, saline-adenine-glucose-mannitol (SAGM) is mixed with the RBC. Further modification of RBC components such as washing, deglycerolizing, irradiation and cytomegalovirus (CMV) testing are covered in Chapter 15 of this Guide. Indications The primary indication for a RBC transfusion is the augmentation of the oxygen-carrying capacity of the blood. Therefore, RBC transfusion is indicated in patients with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with bone marrow suppression may be indications for RBC transfusion. In patients with acute blood loss, volume replacement is often more critical than the composition of the replacing fluid(s). Effective oxygen delivery depends not only on the hemoglobin level, but on the cardiovascular condition of the individual. Younger people, therefore, will typically tolerate lower hemoglobin levels than older patients. Patients who develop anemia slowly develop compensatory mechanisms to allow them to tolerate lower hemoglobin values than patients who become acutely anemic. The decision to transfuse anemic patients should be made in each individual case. There is no uniformly accepted hemoglobin value below which transfusion should always occur. However, many studies and guidelines support the use of a restrictive transfusion strategy both in the intensive-care unit (ICU) setting and with postoperative anemia. Clinical Guide to Transfusion (On-line edition at www.transfusionmedicine.ca) Chapter 2 (Updated March 2013): Page 2 of 16 Clinical Guide to Transfusion 2. Blood Components Contraindications RBC should not be given for volume replacement or for any reason other than correction of acute or chronic anemia when non-transfusion alternatives have been assessed and excluded. The decision to transfuse should not be based on a single hemoglobin or hematocrit value as a trigger without considering all critical physiologic and surgical factors affecting oxygenation in that patient. Dose and Administration RBC compatibility testing must be performed before RBC transfusion unless the situation is life threatening, or unless
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